Arterial Remodeling In Stable Versus Arterial Remodeling In Stable Versus Unstable Coronary Syndromes: Unstable Coronary Syndromes: An Intravascular Ultrasound Study An Intravascular Ultrasound Study Paul Schoenhagen, MD,FAHA Paul Schoenhagen, MD,FAHA Steven E Nissen, MD,FACC Steven E Nissen, MD,FACC E Murat Tuzcu, MD,FACC E Murat Tuzcu, MD,FACC The Cleveland Clinic The Cleveland Clinic Foundation Foundation
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Arterial Remodeling In Stable Versus Unstable Arterial Remodeling In Stable Versus Unstable Coronary Syndromes: Coronary Syndromes:
An Intravascular Ultrasound StudyAn Intravascular Ultrasound Study
Paul Schoenhagen, MD,FAHAPaul Schoenhagen, MD,FAHA
Steven E Nissen, MD,FACCSteven E Nissen, MD,FACCE Murat Tuzcu, MD,FACCE Murat Tuzcu, MD,FACC
The Cleveland Clinic FoundationThe Cleveland Clinic Foundation
BackgroundBackground
• Originally, Glagov described arterial remodeling as an Originally, Glagov described arterial remodeling as an increase in external elastic membrane area within increase in external elastic membrane area within atherosclerotic lesions.atherosclerotic lesions.
• In early CAD, remodeling maintains lumen area despite In early CAD, remodeling maintains lumen area despite increasing plaque burden.increasing plaque burden.
• Although first observed in necropsy Although first observed in necropsy studiesstudies, remodeling , remodeling has been confirmed has been confirmed in vivoin vivo by intravascular ultrasound. by intravascular ultrasound.
• The relationship between remodeling and various clinical The relationship between remodeling and various clinical ischemic syndromes remains uncertain.ischemic syndromes remains uncertain.
Intravascular Ultrasound
vessel wall/ plaquelumen
IVUS Catheter
Objectives and Study DesignObjectives and Study Design
• • Retrospectively analyze intravascular ultrasound images in a Retrospectively analyze intravascular ultrasound images in a series of patients with either stable angina or recent onset of series of patients with either stable angina or recent onset of unstable symptomatology.unstable symptomatology.
• • Examine the relationship between clinical presentation and plaque Examine the relationship between clinical presentation and plaque features at the culprit lesion, including:features at the culprit lesion, including:
• Presence, direction and extent of arterial remodeling Presence, direction and extent of arterial remodeling
Ostial or bifurcation lesions, Ostial or bifurcation lesions, heavy calcium, image qualityheavy calcium, image quality
Methods: Image AnalysisMethods: Image Analysis
• Intravascular ultrasound images obtained from a Intravascular ultrasound images obtained from a proximal reference site and culprit lesion site.proximal reference site and culprit lesion site.
• Quantitative variables:Quantitative variables:
– EEM area, lumen area, and plaque areaEEM area, lumen area, and plaque area
Stable Presentation and Negative RemodelingStable Presentation and Negative Remodeling
Proximal ReferenceProximal Reference LesionLesion
EEMEEM = 10.5 mm = 10.5 mm22 EEMEEM = 7.5 mm = 7.5 mm22
Mixed Morphology with Remodeling Index = 0.71
Schoenhagen et al. Circulation 2000; 101:598-603
Unstable Presentation: Positive RemodelingUnstable Presentation: Positive RemodelingEcholucent Plaque with Remodeling Index = 1.42
Proximal ReferenceProximal Reference
EEMEEM = 14.3 mm = 14.3 mm22 EEMEEM = 20.3 mm = 20.3 mm22
Culprit LesionCulprit Lesion
Schoenhagen et al. Circulation 2000; 101:598-603
LimitationsLimitations
• Selection bias:Selection bias:– The cohort included only relatively severe lesions The cohort included only relatively severe lesions
selected for pre-interventional ultrasound imaging.selected for pre-interventional ultrasound imaging.
• Presence of ultrasound catheter within severe Presence of ultrasound catheter within severe lesions may alter vessel geometry.lesions may alter vessel geometry.
• Classification of plaque morphology based upon Classification of plaque morphology based upon subjective visual criteria.subjective visual criteria.
ConclusionConclusion
• Significant differences in ultrasound characteristicsSignificant differences in ultrasound characteristicsbetween unstable and stable lesions:between unstable and stable lesions:
– Greater plaque burden despite similar luminal narrowingGreater plaque burden despite similar luminal narrowing
– Greater extent of positive remodelingGreater extent of positive remodeling
• A prospective study of the relationship between clinical A prospective study of the relationship between clinical presentation and plaque morphology is warranted:presentation and plaque morphology is warranted:
– Hypothesis: Bulky remodeled plaques may be more Hypothesis: Bulky remodeled plaques may be more vulnerable to mechanical forces, thus leading to plaque vulnerable to mechanical forces, thus leading to plaque rupture and acute coronary syndromes.rupture and acute coronary syndromes.
Remodeling and Clinical PresentationRemodeling and Clinical Presentation